Bitter Pill May Force Hmos Out Of Denial

November 10, 1999|By David Greising.

We're missing something in all this celebration of UnitedHealth Group's plan to let doctors decide what kind of treatment their patients should receive. We're getting way ahead of ourselves hoping other HMOs will copy the program and reduce health-care hassles for all of us.

We're not thinking of the pain this new system will cause.

What about those poor people in the Denials Department at all these HMOs? Hundreds of health-care veterans have spent careers honing their denial skills.

They can say no to doctors, no to patients, no to nurses, spouses and pets. They can deny medical care by phone, fax or e-mail.

"Non," "Nein," "Nyet" and "No" (that's Spanish): They can refuse treatment in any language. For any reason, or for no reason at all.

It's a blow for the Red Tape department, too.

They've spent years devising the most prying, detailed forms outside of the National Security Agency. Out of Red Tape Research & Development has come forms for everything from seeing the heart specialist to visiting Grandma at Thanksgiving.

They've trained patients to apply, in triplicate, for permission to watch "ER."

Through bureaucratic creep, they've grown their ranks and deployed more red tape than all the package wrappers in Santa's workshop. Yet, with a sudden change of policy, hundreds of them could be gone.

UnitedHealth Group's plan is bad news for the industry's highly paid Mouthpiece Department, too. You know, the people who professionally put happy faces on tales of HMO woe.

HMO opponents made hay from the story of a patient who developed a brain hemorrhage after a doctor couldn't convince an HMO to pay for a brain scan. They jumped on the one about an end-stage cancer patient who couldn't get approval for a hospital stay.

For each of the dozens of examples revealed last summer in a study by the Kaiser Family Foundation, some hack HMO critic jumped in to criticize the industry. And for each of the complaints, an image spinner stood by and valiantly defended the HMOs.

Let's not forget the firm that's causing all this trouble: UnitedHealth Group.

No surprise there. For years, UnitedHealth has pushed plans that reduce the emphasis on the Denials, Red Tape and Mouthpiece departments.

They've allowed patients to see specialists without permission of their primary-care doctors. They have let people use little more than common sense when deciding whether to visit emergency rooms--the sanctum sanctorum of the higher church of health care.

UnitedHealth has made these changes while keeping costs in line with the industry's standard increases. And a two-year study of the program indicates that costs may also not increase beyond the industry average under the new system.

UnitedHealth is creating new forms of HMO work, too. But strangely, the new tasks involve pro-active patient contact. UnitedHealth will track patients' case histories, and then contact patients and doctors if patients seem to be missing preventive care.

By making certain that heart patients take their medicines or that women get mammograms, UnitedHealth workers may intervene before people develop costly and life-threatening conditions.

Much of the work that historically went into Denials, Red Tape and Mouthpiecing may soon go into patient care. "We're moving resources from one activity over to another activity," says William Whitely, chief executive of United HealthCare of Illinois.

Yeah, right. Tell that to all the people in Denials, Red Tape and Mouthpiece if they suddenly find there's no meaningful work left to do.